“Who sinned, this man or his parents, that he was born blind?” Asked of Jesus by the religious authorities of the day, this question haunts many conversations about social welfare and health policy. Self-reliance—that people should “get what they earn”—is embedded in America’s cultural mythology. In some subtle way, people in poor health must be responsible for their condition and simply have to pay when illness strikes.
This is the moral question underlying health policy: Who should bear the cost of caring for the sick? That we are neither wholly blameless or nor wholly guilty for the state of our health is the Gordian knot we labor in vain to untie. We know that smoking often causes lung cancer and obesity can trigger diabetes. But not all lung cancer comes from smoking and diabetes has other triggers. We’re not willing to deny care to victims of either disease. We admire self-reliance but also sense the injustice in “blaming the victim” for diseases and conditions that have no known link to personal decisions (and some that do). As the Republican Congress and the Trump Administration seek to unwind Barack Obama’s Affordable Care Act (ACA), this “who pays?” question takes center stage. Read more »
Last week we looked at how the Affordable Care Act and the Republican replacement plan changed health insurance for those of us who buy insurance either through our employers or on the individual market. This week we’ll look at how the ACA and the new plan change access to health insurance for people with low income.
The ACA expanded Medicaid in two ways. First, it added adults in poverty to the program, not just poor children and their parents. Before the ACA, low-income adults without dependent children were ineligible for Medicaid in 26 states—the cost of doctor visits, hospital stays, prescription drugs—all had to be paid in cash. The ACA also pushed Medicaid eligibility up to 138% of the federal poverty line (FPL) for everyone (although some states, like New York and California, were already there). For context, the FPL for a single adult is $12,060 and, for a family of 3, $20,420.
At least until a group of states took the matter to the Supreme Court, which ruled that Congress could not require the Medicaid expansion, even though most of the cost was shared among all federal taxpayers. Currently, 19 states have chosen not to expand Medicaid eligibility. Read more »
Will more be insured? Will we have the health professionals to meet their needs?
Last month’s column looked at how health insurance eligibility changed under ACA and explored the “coverage gap” in states choosing not to expand Medicaid. This week we’ll explore other implications of this revolutionary change in how health insurance is secured and paid for.
On balance, will the share uninsured go down?
Cutting the ranks of the uninsured is a key objective of ACA. Not all of the 8 million who signed up for new plans were previously uninsured: According to early surveys, two thirds to three quarters of these enrollees were changing plans. No surprise here. ACA offers subsidies that are significant for many, making the Marketplace plans very attractive for those who qualify. Others who didn’t qualify for subsidies still found the Marketplace plans a good deal. Competition spurred by the Marketplace drove down prices for nonemployer plans in some states, including New York.
Yet some will choose to pay the penalty for being uninsured instead of the premiums. Insurers are now required to cover a fixed set of preventative services at no extra cost to the consumer. The law also limits what consumers can be charged for care within a single year. Initially, ACA required that a 2014 policy must cover all costs above $6,350 for singles or $12,700 for families. That’s the “out-of-pocket maximum,” now delayed until 2015. (These deductibles are subsidized for individuals and families below 250% of the poverty line.) This shifts the financial burden of major illness from the insured to the insurer. Both changes make for better insurance—but they cost insurers more and premiums will rise. Read more »
Part 1: Health Insurance Coverage for the Poor
The Affordable Care Act’s initial enrollment period is over and Health & Human Services Secretary Kathleen Sibelius has resigned, having earned a jacket full of Purple Hearts from countless Congressional hearings. What have we wrought?
Make no mistake—this will revolutionize health care delivery in the United States. As the Arab Spring suggests, revolutions can be good or bad. Or both, as in this case.
In the first of a two-part column on the Patient Protection and Affordable Care Act (ACA), let’s focus on how coverage for the poor has changed. Read more »
The health insurance mandate, probably the most visible outcome of the Patient Protection & Affordable Care Act (ACA or Obamacare), goes into effect in January. Enrollment in the health insurance exchanges opens October 1, so much attention has been focused on the premiums: Supporters of the law hope for lower rates; opponents have been widely predicting that rates would soar.
In July, premiums for New York State’s Health Insurance Marketplace were released and revealed two notable facts: First, premiums in the individual market are far below current rates. Second, Rochester has the lowest rates in the state. Read more »
Health care is different from other goods and services.
- As a wealthy society, we aren’t willing to limit access to care based on ability to pay (at least entirely).
- Caveat emptor—let the buyer beware—fails in the face of complexity: The patient (the “buyer”) is often incapable of understanding what is appropriate or necessary and must rely on the provider (the “seller”) for essential advice.
- The pace of technological change outstrips our capacity to set limits on what constitutes adequate care.
- Public policy, operating through payment schema and regulation, is a blunt instrument, influencing the marketplace in both intended and unintended ways. Read more »
Premature childbirth increases the risk of death or a lifetime of disability and nearly always drives up cost. Early care for expectant mothers can help increase the chances of a healthy, full-term pregnancy. Now that the Supreme Court had upheld national health reform and its mandate to carry health insurance, we might hope to see more expectant mothers receiving care early in their pregnancies. Studies suggest that access to health insurance isn’t the only factor, however.
The nation had set a goal for 2010: 90% of pregnant women getting care in the first trimester of pregnancy. In New York and in the Rochester area, we’re not close: in 2010, 79% of mothers in our region started prenatal care that early, higher than the state rate of 73% but largely unchanged over the past decade. Generally speaking, rates of early access to prenatal care haven’t changed much over the past decade, and neither have rates of problems that prenatal care helps prevent, such as low birth weight. Even more troubling, low-income and minority women tend to be less likely to start care early, another stubborn pattern. Read more »
The financial problems of the nation and many large states—California, Illinois, New Jersey and certainly New York—present a problem that is challenging economically and hazardous politically. Since it’s impossible to separate the economics from the politics, it is truly a Gordian knot – rather than untying the knot, Alexander the Great sliced the Gordian knot in two with a single, bold stroke of his sword.
The Congressional Budget Office forecasts the federal deficit to decline from about $1.5 trillion in 2009 to $608 billion in 2014, then rise to nearly $800 billion in 2020. This is a hefty deficit, particularly when you consider that we had a surplus as recently as 2000. Then consider that the cumulative public debt, which currently stands at $7.5 trillion, is expected to nearly double by 2020 to $14 trillion.
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Early this year I wrote about the high deductible health plan (HDHP) and health savings account (HSA) being offered to CGR by Excellus. A look-back seems timely.
Five of us at CGR signed up for the HDHP and HSA combination. With our experience as background, nearly the entire staff selected this option for the coming year. Why?
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Congress is edging closer to passing legislation that restructures health insurance. The Senate and the House are debating compromise bills within their houses, after which a conference committee will seek to reconcile differences between them. With these details still under debate, we conclude our six part series on health reform with a few observations.
Public Option. If private insurance plans are part of the problem, then one solution may be to offer another option, a health insurance plan that is run by the government. At this writing, a “public option” seems likely to survive and become part of the final legislation. The debate over the public option has highlighted a fundamental social tension between those who fear too much government and those who fear too little (discussed in the first column in this series). Like Goldilocks, each of us wants the balance to be “just right.”
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